14-124
(Rev.8-08/4)
b.
TEXAS MOTOR VEHICLE REGISTRATION SURCHARGE
AND/OR TITLE APPLICATION FEE REPORT
21100
DO NOT WRITE IN SHADED AREAS
a. T Code
e.
c. Taxpayer number
d. Filing period
f. Due date
IMPORTANT
h.
g. Name and mailing address (Make any necessary name or address changes below.)
Blacken this box if your mailing
address has changed. Show changes
1.
by the preprinted information.
Blacken this box if you are no
longer in business and write in the
2.
date you went out of business.
Month
Day
Year
i.
j.
INSTRUCTIONS FOR COMPLETING THE
TEXAS MOTOR VEHICLE REGISTRATION SURCHARGE AND/OR TITLE APPLICATION FEE REPORT
The Texas Motor Vehicle Registration Surcharge and/or Title Application Fee must be remitted to the Texas Comptroller on
a monthly basis. Reports should be filed by the 10th day of the month following the report period.
NOTE:
All Texas counties must remit $15.00 of each title application fee to the Texas Mobility Fund (Column B).
Non-attainment counties must indicate the additional $5.00 portion of the title application fee to the Texas
Emissions Reduction Plan, TERP (Column C).
Prior payments include electronic funds transferred for this report period. Include any collections made on prior dishonored
payments in Item 1.
21100
12100
12100
COLUMN A
COLUMN B
COLUMN C
REGISTRATION
TITLE APPLICATION FEE
TITLE APPLICATION FEE
SURCHARGE
TEXAS MOBILITY FUND
TERP
1. Number of registrations
and/or title applications
1a.
1b.
1c.
$
$
$
2. Total registration surcharge and/or
title application fees collected
2a.
2b.
2c.
$
$
$
3. Claim for dishonored payment
3a.
3b.
3c.
$
$
$
4. Total surcharge and/or title application
fee due (Item 2 minus Item 3)
4a.
4b.
4c.
$
5c. Item 4b plus
Item 4c
5c.
* * * DO NOT DETACH * * *
$
$
6. Prior payments
6a.
6c.
$
$
7. Total amount due and payable
7c. Item 5c minus
(Item 4a minus Item 6a)
Item 6c
7a.
7c.
k.
l.
$
8. TOTAL AMOUNT OF MOTOR VEHICLE SURCHARGE AND/OR TITLE
APPLICATION FEE DUE AND PAYABLE (Add Item 7a and Item 7c.)
8.
Taxpayer name
m.
T Code
Taxpayer number
Period
I declare that the information in this document and any attachments is true and
correct to the best of my knowledge and belief.
Taxpayer or duly authorized agent
STATE COMPTROLLER
Make check payable to:
COMPTROLLER OF PUBLIC ACCOUNTS
Business phone
Date
Mail to:
P.O. Box 149360
Austin, Texas 78714-9360
For assistance, call (800) 252-1382 toll free nationwide. The local number in
Austin is (512) 463-4600. The Web address is
333 B
Form 14-124 (Rev.8-08/4)
1
Form 14-124 - Texas Motor Vehicle Registration Surcharge And/or Title Application Fee Report
Financial
Form 14-125 - Texas Motor Vehicle Seller-financed Sales Tax Surcharge Declared Estimate And Prepayment
Financial
